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Creating a Segregated Medical Profession:
African American Physicians and Organized
Medicine, 1846-1910
Robert B. Baker, PhD; Harriet A. Washington; Ololade Olakanmi; Todd L. Savitt, PhD; Elizabeth A.
Jacobs, MD, MPP; Eddie Hoover, MD; Matthew K. Wynia, MD, MPH; for the Writing Group on the
History of African Americans and the Medical Profession
An independent panel of experts, convened by the American Medical Association (AMA) Institute for Ethics, analyzed
the roots of the racial divide within American medical organizations. In this, the first of a 2-part report, we describe 2
watershed moments that helped institutionalize the racial
divide. The first occurred in the 1870s, when 2 medical societies from Washington, DC, sent rival delegations to the
AMA’s national meetings: an all-white delegation from a
medical society that the US courts and Congress had formally censured for discriminating against black physicians;
and an integrated delegation from a medical society led by
physicians from Howard University. Through parliamentary
maneuvers and variable enforcement of credentialing standards, the integrated delegation was twice excluded from
the AMA’s meetings, while the all-white society’s delegations were admitted. AMA leaders then voted to devolve
the power to select delegates to state societies, thereby
accepting segregation in constituent societies and forcing
African American physicians to create their own, separate
organizations.
A second watershed involved AMA-promoted educational
reforms, including the 1910 Flexner report. Straightforwardly
applied, the report’s population-based criterion for determining the need for physicians would have recommended
increased training of African American physicians to serve
the approximately 9 million African Americans in the segregated south. Instead, the report recommended closing all
but 2 African American medical schools, helping to cement
in place an African American educational system that was
separate, unequal, and destined to be insufficient to the
needs of African Americans nationwide.
Keywords: education n African Americans n National
Medical Association n National Medical Association
J Natl Med Assoc. 2009;101:501-512
Author Affiliations: The Union Graduate College–Mount Sinai School of
Medicine Bioethics Program, and Department of Philosophy, Union College, Schenectady, New York (Dr Baker); DePaul University College of Law,
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Chicago, Illinois (Ms Washington, visiting scholar); Institute for Ethics, American Medical Association, Chicago, Illinois (Dr Wynia and Mr Olakanmi);
Department of Medical Humanities, Brody School of Medicine, East Carolina University, Greenville, North Carolina (Dr Savitt); Division of General
Medicine, Stroger Hospital of Cook County and Rush University Medical
Center, Chicago, Illinois (Dr Jacobs); National Medical Association, Washington, DC (Dr Hoover, editor, Journal of the National Medical Association);
The University of Chicago Hospitals, Chicago, Illinois (Dr Wynia).
Corresponding Author: Matthew K. Wynia, MD, MPH, Institute for Ethics, American Medical Association, 515 N State St, Chicago, IL 60610
(matthew.wynia@ama-assn.org).
Introduction
T
he American Medical Association (AMA) Institute for Ethics convened an independent panel
of experts, with the support of NMA and AMA
leadership, to review and analyze the historical roots
of the racial divide within American medical organizations. In a prior report,1 (available at our project w†eb
site, http://www.ama-assn.org/go/AfAmHistory), we
provided a brief summary of the panel’s finding across
the entire period from the founding of the AMA to the
civil rights era: 1846-1968. This report provides a more
detailed look at 2 watershed moments between 1846 and
1910. In this period the AMA developed a state-based,
federated structure that effectively excluded most African American physicians from the organization. This
was also a period of change in medical education, in
which the AMA played a significant role and which
had foreseeable (and, in fact, foreseen) harmful effects
on the education of African American physicians. The
ill effects of these actions on the health and health care
of African American patients is impossible to calculate
with precision, but they left African American physicians with few opportunities for medical and postgraduate training and continuing education, and reduced
African American patients’ access to health care from
well-trained medical professionals.
Methods
Panel members were initially selected by AMA Institute for Ethics staff, and additional members were added
VOL. 101, NO. 6, JUNE 2009 501
African Americans and Organized Medicine
by the panel. The panel was convened with the support of
NMA and AMA leadership, and both were asked to provide comments on drafts. However, AMA and NMA leadership were not asked to approve the members of the panel
or the contents of manuscripts prior to submission.
For source materials, the panel examined primarily
AMA, NMA, and newspaper archives, the latter via
online databases (http://www.accessible.com, http://bsc.
chadwyck.com, and http://www.proquest.com). In addition, we searched Medline using keywords race, segregation integration, and the MesH heading prejudice. A
number of books were especially useful and are listed in
a bibliography at the project Web site (http://www
.ama-assn.org/go/AfAmHistory).
Early in its work process, the panel decided to avoid
making moral judgments about the intent and motivations of actors in this history. Primary sources about
motivation are scant to nonexistent and, insofar as motivations are discernible, they appear mixed or obscured,
perhaps even to the actors themselves. The results of
decisions, by contrast, are clearer, and so this is where
the panel elected to focus its attention. Some broader
social historical context is provided both here and in supplemental materials available on the project Web site;
however, space constraints and the limits of our project
preclude a full explication of the many sociopolitical factors that may have been reflected in the historical episodes we describe.
Creating a United Society in a
Divided Nation
Today, membership in medical societies is largely
voluntary, and many physicians choose not to join. But
this was not always the case. Between 1846 and 1910,
medical societies were the crucibles in which the organized profession of medicine was formed.2 They were
where one met and developed relationships with professional colleagues—people one could call upon for a second opinion or to assist in surgery. They were also a
forum in which to present papers and learn the latest
techniques and treatments. Beyond these direct educational functions, hospital admitting privileges came to
be closely linked to medical society membership, along
with advanced training opportunities. Moreover, medical society membership was sometimes linked to state
licensing and regulatory bodies, and to one’s ability to
obtain the bank loans necessary to establish a practice
and to purchase newly important scientific equipment,
such as stethoscopes and microscopes. In sum, between
1846 and 1910 exclusion from these societies came to
mean professional isolation, heightened barriers to adequate training, limitations on professional skills and
contacts, and severe constraints on sources of income.2-9
The AMA was conceived as a confederation of US
medical societies, colleges, and institutions—the majority being state and local societies—with the avowed pur502 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
poses of creating a “uniform and elevated standard…for
the degree of MD;” providing a common code of medical
ethics; and promoting the profession’s “interests,” “honor,”
“respectability,” “knowledge,” and “usefulness.” 2(xxvi) The
idea of a single, unified, national medical society, however, ran against the strong tide of pre–Civil War regional
divisions over the question of slavery. In slave states, most
African Americans were property,10 and physicians owned
African American slaves and/or made a living through the
patronage of slaveholding plantations.10-12
Racism was present in the North as well and assumptions about the mental inferiority of African Americans
were prevalent in the North and South alike.6(242) African
Americans, like James McCune Smith (1813-1865) of
New York, were forced to travel abroad for medical education after being rebuffed from American schools on
the grounds of race.13 (Smith book) Three African American
students (Daniel Liang, Isaac Snowden and Martin Delaney) were initially admitted into Harvard in 1850, but
were expelled when a group of 27 white students protested.14 Within medicine, scientific racism, which inculcated the belief that blacks were physiologically different from whites in ways that justified enslavement, was
common in the United States and Europe, with many
prominent US physicians at its vanguard.3,12,15,16 For
example, the AMA’s Committee on Medical Sciences
reported in 1850 that, “The Negro brain is nine cubic
inches less than the Teutonic [i.e., white].”17
Nevertheless, some physicians directly challenged
these theories. For example, Philadelphian John Bell
(1796-1872), an ardent abolitionist and chair of the committee that drafted the AMA’s original Code of Medical
Ethics in 1847, re-published a synopsis of a remarkable
paper by one of the few European proponents of egalitarianism, the “Great Physiologist of Heidelberg” Friedrich Tiedemann, in his Eclectic Journal of Medicine, in
which Tiedemann found “no perceptible difference
[between] the brain of the Negro and that of the European.”18 Tiedemann had also noted that, after taking
account of body size, he had proven, “by measuring the
cavity of the skull in Negroes and the men of the Caucasian, Mongolian, American, and Malayan races, that the
brain of the Negro is as large as that of the European,” a
finding that directly contradicted widely held beliefs of
the time. 19 Moreover, some Northern medical schools
and medical societies were successful in opening their
doors to African Americans. Rush Medical School (Illinois) awarded the first American MD degree to an African American, David Jones Peck (1826/1827-?) in
1847.20 And in 1854, the Massachusetts Medical Society
(MMS) accepted into membership John Van Surly
DeGrasse (1825-1868), who was probably the first African American member of any state medical society.21
In 1846, when a national conference on medical education closed by recommending the formation of a
national medical society, the AMA, to address the issues
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African Americans and Organized Medicine
of medical and pre-medical education on an on-going
basis it also mandated that this society have a national
code of medical ethics. Written by Bell and Isaac Hayes
(1796-1879) and a small committee, this code was
adopted by the full AMA at its founding meeting in
1847. The code made no mention of race,2(xxvi-xxvii, 324-34) but
espoused ideals of equal treatment on the basis of scientific qualifications alone. It noted that, “A regular medical education furnishes the only presumptive evidence
of professional ability and acquirements, and ought to
be the only acknowledged right of an individual to the
exercise and honours of his profession” and that “no one
can be considered as a regular practitioner, or fit associate in consultation, whose practice is based on exclusive
dogma, to the rejection of the accumulated experience
of the profession, and of the aids furnished by anatomy,
physiology, pathology, and organic chemistry.”2(329) The
exclusion clause was specifically directed against socalled “irregulars,” like homeopaths, who subscribed to
alternative theories of sickness and therapeutics that the
AMA members deemed unscientific, and who, at the
time, successfully competed with regular practitioners
in the medical marketplace.
The AMA code and other regulations focused on
medical practice and conduct and no mention of race is
found in AMA records of the time, therefore it is
unknown whether any African American physicians
sought to serve as AMA delegates in the organization’s
very early years. It is also uncertain whether any African
Americans served as delegates to an AMA meeting in
this era, though this seems unlikely. Rather, given the
way future events unfolded, it seems likely that to have
included African Americans would have raised the ire of
many physicians who, despite the language of the Code,
saw the AMA as both a scientific fraternity and an exclusive social gathering.
Unity Through Exclusion
Pivotal events that would set the role of African
Americans in organized American medicine unfolded at
a series of meetings in the 1870s. To appreciate these
events, one needs to recognize that this was a period of
reconciliation and reform in America, during which the
entire nation was searching for union even as it debated
the status of newly freed slaves. Presidents Abraham
Lincoln (1809-1865) and Andrew Johnson (1808-1875)
favored a moderate, conciliatory approach to Reconstruction policy, with the goal of quickly reuniting the
country.22 By 1870, every secessionist Southern state
had been readmitted to the Union. Yet, they were readmitted to a new nation in which radical Republicans had
ratified the 13th, 14th, and 15th Amendments – granting
certain civil and political rights to newly emancipated
slaves. These rights, however, were immediately sabo-
Table 1. American Medical Association Meeting Locations and Presidents in the Years Surrounding the US
Civil War Were Balanced Between Northern and Southern Statesa
Year
Preliminary convention 1846
1847
1848
1849
1850
1851
1852
1853
1854
1855
1856
1857
1858
1859
1860
1861
1862
1863
1864
1865
1866
1867
1868
1869
1870
a
Meeting Location
NY
PA
MD
MA
OH
SC
VA
NY
MO
PA
MI
TN
DC
KY
CT
Meeting deferred due to Civil War
Meeting deferred due to Civil War
IL
NY
MA
MD
OH
DC
LA
DC
AMA President (State)
J. Knight (CT)
N. Chapman (PA)
A.H. Stevens (NY)
J.C. Warren (MA)
R.D. Mussey (OH)
J. Moultrie (SC)
B.R. Wellford (VA)
J. Knight (CT)
C.A. Pope (MO)
G.B. Wood (PA)
Z. Pitcher (MI)
P.F. Eve (TN)
H. Lindsly (DC)
H. Miller (KY)
E. Ives (CT)
A. March (NY)
N.S. Davis (IL)
N.S. Davis (IL)
D.H. Storer (MA)
H.F. Askew (DE)
S.D. Gross (PA)
W.O.Baldwin (AL)
G. Mendenhall (OH)
Southern states: those with a history of slave holding and trading through the time of the Civil War are bold.
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African Americans and Organized Medicine
taged by repressive legislation. As early as November
1865 punitive Black Codes were being passed in southern states, restricting African Americans’ activity and
movements, often requiring them to remain on plantations, sometimes even as indentured servants.22(199-201),23
These codes, in turn, raised the ire of many northern
abolitionists, who thought (correctly) that they were an
attempt to maintain a society that was “as near to slavery
as possible.”22(199)
The AMA, meanwhile, carefully maintained a pattern
of North-South balance in locating national meetings
and electing presidents both before and after the Civil
War—presumably in an attempt to maintain professional
unity despite rising regional tensions (Table 1). Following the war, as early as 1868 the AMA meeting included
delegations from six Southern states24; and by 1869, the
annual meeting was held in New Orleans with William
Baldwin (1818-1886) of Alabama as president. “Eight
years ago we were separated by civil war … [that] engendered the bitterest feeling in every other national organization,” Baldwin observed. “[I]t has been left to the
[AMA] to teach … charity and forgiveness.” 25(pp56-60), a
The AMA’s plan to maintain professional unity was
soon tested, however, when three black physicians—
Alexander Thomas Augusta (1825-1890), Charles Burleigh Purvis (1842-1929), and Alpheus W. Tucker
(unknown dates)—sought recognition as delegates from
the District of Columbia’s new, racially-integrated
National Medical Society of the District of Columbia
(NMS; not to be confused with the NMA, founded in
1895) at the AMA’s 1870 meeting in Washington, DC
(Figure 1).26,27 The NMS had been formed in reaction to
racial exclusion on the part of the Medical Society of the
District of Columbia (MSDC).27 After their initial exclu-
sion, these African American physicians appealed to
congress, which had direct authority over the District of
Columbia, for redress. In 1869 a congressional investigation found that the MSDC had indeed refused to admit
these same three, otherwise-qualified black physicians,
“solely on account of color.”29(p2550) However, congress
provided no remedy, so these physicians founded an
integrated society: the NMS.
Since at this time the AMA was a confederation of
municipal, county, and state medical societies, medical
hospitals, and other medical institutions, any medical
institution of “regular” physicians that abided by the
AMA Code of Ethics could send delegates to the national
AMA meeting. When the AMA held its 25th meeting in
Washington DC in 1870, both the NMS and the MSDC
sent delegates —the all-white MSDC urged massive
attendance by white physicians in an attempt to stack a
potential vote against admission of the integrated NMS
delegation.28 Both the MSDC and the NMS filed ethics
complaints against each other. The MSDC challenged
the inclusion of the NMS delegation, which comprised
not only the 3 black physicians but a number of sympathetic white physicians as well,291 on the grounds that the
NMS “was formed in contempt of,” and “[had] attempted,
through legislative influence, to break down,” the
MSDC.26(p173-174) In other words, the MSDC opposed the
NMS because NMS members had petitioned Congress
to address racial discrimination within the MSDC. The
NMS, in turn, charged the MSDC with licensing “irregular” practitioners.
Quite independently, dissident members of another
society, the Massachusetts Medical Society had also
charged their own society with accepting “irregulars,”
specifically homeopaths, into membership. 30(pp26,53-54),31
Figure 1. Alexander T. Augusta (1825-1890) and Charles B. Purvis (1842-1929)
Three African American physicians were denied entrance into the Medical Society of the District of Columbia in 1869 and the annual
convention of the American Medical Association in 1870: Alexander Thomas Augusta (left), Charles Burleigh Purvis (right), and Alpheus
W. Tucker (not pictured). In: Alexander T. Augusta. Arlington National Cemetery Web site. http://www.arlingtoncemetery.net/ataugust.
htm. Accessed January 28, 2008.; and Morais H. The History of the Negro in Medicine. 1st ed. New York, NY: Association for the Study of
Negro Life and History and Publishers Co Inc; 1967:52.
a See also, Blight, D. Race and Reunion: The Civil War in American Memory. Cambridge MA: Belknap Press of Harvard University; 2002.
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Homeopaths, as noted earlier, were characterized by the
AMA Code of Ethics as practicing “an exclusive dogma
to the rejection of the accumulated experience of the
profession” and their exclusion was considered a defining issue for the AMA.9(114-115),19(99-100),32(174)
Since all of these cases involved allegations that a
society had violated the Code of Ethics, all three were
referred to the AMA’s Committee on Ethics. Following
protracted deliberation – lasting almost the entire duration of one meeting, possibly stalling to avoid making a
controversial decision until just before the meeting
adjourned26 – the Committee found that the charge that
the MSDC granted licenses to irregulars was “not of a
nature to require the action of the [AMA]” because it
was a matter for Congress to address, and recommended
inclusion of the MSDC’s all-white delegation.30(p54) The
Committee also urged recognition of the delegates from
Massachusetts, even though the charge that their society
accepted irregulars as members was “fully proved” and
“plainly in violation of the Code of Ethics”30(p29) —
observing that the charges should have been first lodged
locally. Therefore, the Massachusetts society was
instructed to expel any irregulars from membership
before the next AMA meeting, which they did.31
With respect to the integrated NMS, however, the
Committee was divided, 2 to 3. Two of the AMA’s founders led the ensuing debate: AMA vice-president Alfred
Stillé (1813-1900), speaking for the Committee’s minority, recommended recognition of the NMS delegation.30(pp5556)
Nathan Smith Davis (1817-1904), whom the AMA
had twice elected as its president during the Civil War
(Table 1) and would later laud as its “father,”29(p603),33
spoke for the Committee’s majority and urged exclusion
of all NMS members, including all of the white members who supported the integrated society30(pp53-55) When
the issue was put to a roll call vote (in which the 36 delegates from the MSDC, but no NMS members, were
allowed to vote), the minority report was tabled (114 to
82) and the majority report adopted. As a result, the integrated NMS delegation was excluded. 30(pp56-58)
Following the vote, a written clarification of the Davis
committee’s recommendations was requested. The next
day, before Davis’ clarification was presented, two Massachusetts delegates who had supported the inclusion of
the NMS delegates, the anti-abortionist Horatio R. Storer
(1830-1922) and colleague John L. Sullivan (sometimes
referred to as O’Sullivan, unknown dates) expressly
raised the issue of race. Sullivan proposed that the AMA
adopt the policy that “no distinction of race or color shall
exclude from the Association persons claiming admission and duly accredited thereto.”30(p65) According to the
New York Times this proposal was submitted amid,
a storm of hisses, which compelled him [Sullivan]
to stop. Cries of ‘Go on; go on!’ were heard, and
he said he would do so when the serpents became
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
quiet. He then finished reading [the proposal],
and was allowed to speak five minutes.34
But AMA vice-president Lewis A. Sayre (18201900) of New York proposed – and the delegates voted
to approve – that action on Sullivan’s proposal be postponed so that Davis could present the written report
clarifying the Committee’s reasoning for not admitting
delegates from the NMS.
Davis’ clarification stated that “if the medical department of Howard University had chosen to send any delegates who are not members of [the NMS] there is nothing whatever in [this] report to prevent them from being
received [as delegates].” As to the NMS and its members, they were in violation of various by-laws of the
MSDC, and,
they had used unfair and dishonorable means to
procure the destruction of the [MSDC] by inducing
congress to abrogate their charter. Each and all of
these charges were…fully proved. Therefore if we
have any regard for the laws of the land, or the ethics of our medical organizations, the undersigned
could not come to any other conclusion.30(pp65-66)
Sullivan’s proposal that no distinction of race or color
shall exclude someone from the AMA was then voted
upon. It lost by a vote of 106 to 60.
Storer then proposed what can only be seen as an effort
to save face: a resolution stating that Davis, having
distinctly stated and proved that the consideration
of race and color has had nothing whatsoever to
do with the decision of the question of the Washington delegates, and inasmuch as charges have
been made in open session to-day attaching the
stigma of dishonor to parties implicated…therefore the report of the majority of the Committee
on Ethics be declared, as to all intents and purposes, unanimously adopted.
According to the minutes, however, Davis never
mentioned race or color. He merely stated that nothing
in the report excluded the faculty of the Howard medical
department (many of whom were white). One southern
medical journal, in an editorial favoring exclusion of the
NMS, called this resolution “a kind of placebo—an
effort to pore [sic] oil on troubled waters, even at the
hazard of strict interpretation of truth.”28(p201) In any event,
Storer’s motion passed, 112 to 34.30(pp66-67)
The AMA thus excluded an integrated medical society through selective enforcement of membership standards. At the same meeting it allowed leniency to 2 allwhite delegations that had clearly breached scientific
credentialing standards specified in its code of ethics by
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African Americans and Organized Medicine
dards of collegial behavior to a delegation with black
members—and, immediately thereafter, declined to adopt
a policy of nondiscrimination, and finished the meeting
by officially absolving itself of the charge of racism.
The AMA’s decision to provide itself instant absolution is evidence of, if not guilt, at least recognition that
the decision had the effect of racial discrimination, which
some physicians found condemnable. Indeed, an unnamed
white commentator, reflecting on the decision, wrote in
1870: “I doubt whether, in the last 50 years, a national
scientific body has convened anywhere that would have
excluded a competent scientist on the ground of
color.”26(p178) He noted further that it was contrary to the
“ethics” and “avowed purpose” of the AMA “to propose
tests for membership totally irrelevant to capacity or
character.”26(pp172,176) But, despite this, the AMA had put up
“new barriers to entrance”26(p177) and, in doing so, “unharnessed itself from its code of ethics.”2(p180) And “the profession as well as the laity know…[that the AMA’s action]
was aimed at the exclusion of the colored physician,” yet
it had to be “made to appear that they were not excluded
on the ground of color…[because the act was] somewhat
monstrous, and would need plausible excuse before
others.”26(pp172,175) (The entire text of this remarkable 1870
commentary is available at our project Web site.)
Despite Davis’ public statement that nothing whatsoever in the 1870 report of the Committee on Ethics would
prevent members of the Howard faculty from being
“received” as AMA delegates, when members of the Howard faculty applied to be received as delegates in 1872,
Davis argued that the Howard faculty members could not
be received “on account of want of good standing on the
part of those institutions, as indicated by the action of this
Association at its annual meetings in 1870.”35(p53) Davis further alleged that Howard faculty should be excluded
because the institution admitted women to its faculty and
because it allowed members to practice without a license
from the MSDC (which still refused to admit or license
black physicians). Davis strove to appear impartial in
adducing “evidence” favoring exclusion, but at one point
he misrepresented an 1871 vote of 83 to 26 to postpone
discussion when the hour grew late as a lopsided vote
against admitting institutions with women. In fact, the
1871 vote to exclude institutions admitting women was
quite close: 45 against admission vs 41 in favor.36
Dr Robert Reyburn (1833-1909) rose to defend the
Howard delegation in 1872. He observed that the
MSDC’s licensing practices had been struck down “by
the local courts [as discriminatory]; and being considered unconstitutional, could not be enforced.” 35(p55) Reyburn admitted that “Howard University…received all
who applied for medical education, without distinction
of color or of sex….[in the belief that] every human
being should be allowed the right to the highest developb
ment that God has made him capable of.”35(p55)
Dr Samuel C. Busey (1828-1901) of the MSDC
responded. Acknowledging the truth of Reyburn’s
claims, Busey proclaimed that the MSDC “had not
attempted to maintain its [licensing] authority through
the local courts” after a judge had declared its procedures unconstitutional, because
The members of the profession in the District of
Columbia, standing upon its honor and dignity
appeal neither to the courts nor legislative bodies, but to their peers—to this body, which was the
only competent arbiter and tribunal to determine
questions of medical honor, or ethics, and professional decorum.35(p55)b
After this exchange, the AMA members voted to accept
Davis’ report, including the recommendation to exclude the
Howard faculty delegates, “by a very large majority.”35(p59)
As we noted in the methodology section, the focus of
this paper is on the effects of actions, not the intentions
of actors. Nonetheless, one can summarize that Davis
reneged on his public statement not to use the 1870
report against future Howard delegations and misrepresented a prior decision in seeking evidence to support
exclusion. For its part, the assembled AMA more than
once voted to seat the all-white MSDC but not the integrated NMS or Howard delegations, even though a court
had found the MSDC’s licensure practices discriminatory and unconstitutional and the organization had
licensed irregular practitioners. Finally, the minutes of
the 1872 meeting also state that the ultimate grounds
given for denying admission to the integrated Howard
delegation in 1872 was that the school admitted women
students and faculty—a curious linkage of race and gender. In the end, although the AMA never adopted Jim
Crow–like regulations formally excluding women or
blacks from attending national meetings, after repeated
attempts of integrated delegations and those from institutions admitting women to be recognized at AMA
national meetings between 1870-1872, the racial and
gender composition of the AMA remained unchanged—
uniformly white and male—and the AMA’s national scientific and social meeting was, in consequence, an exclusive white man’s club.
Leaving Racial Segregation to
the States
In 1873, Davis offered a proposal to put an end to
seemingly interminable squabbles over seating delegations: delegations would henceforth be restricted to state
and local medical societies—and state societies, not the
national AMA convention, would determine which local
societies should be officially recognized by the AMA.37
Minutes House Delegates 25th Annual meeting AMA, 1872, p. 55
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African Americans and Organized Medicine
Davis’ proposal, adopted in 187438, conceivably had various motivations but, regardless of intent, it was a dramatic shift of power to the state societies, functionally
transforming the AMA into a state society-based federation. The effects of this transformation were clear:
because many AMA-affiliated medical societies, and all
of those in the south, where the vast majority of blacks
lived, openly practiced racial exclusion, the AMA’s new
structure effectively excluded most black physicians
from the AMA.
In the late 1800s, an increasing number of northern
societies elected to admit women, which ushered some
into AMA membership. In 1876, the Illinois delegation
to the national AMA convention included Sarah Hackett
Stevenson (1841-1909), the AMA’s first woman
member.39(p16) She was admitted into the AMA’s national
meeting by that year’s president, James Marion Sims
(1813-1883), with the statement that
if any woman [in] the medical profession makes
such a reputation…as to be sent as a delegate…
we are bound to receive her. And if any colored
man should rise to the dignity of representing a
[society] we must receive him as such.39(p93)
Note again the curious link between admitting a member
of another gender and admitting a member of another
race. Note further that the statement implies that there
had been no black AMA delegates prior to 1876. Before
1888 the AMA was a confederacy, and thus there were no
individual members of the AMA as such, only delegates
to the national AMA convention and members of organizations that belonged to the AMA. A change in the bylaws
in 1888 made all members of constituent state societies
“de facto permanent [AMA] members.”40(pp477-478),41 Since
some northern state societies had African American
members at the time, the AMA probably gained its first
African American members in 1888.
racial exclusiveness”51 and included white members.
The AMA similarly “boasted itself as exclusive only of
the false in science and character”26 and, after 1888, had
a few northern black members. Among the NMA’s
founders was at least 1 African American AMA member, Daniel Hale Williams (1856-1931, Figure 2), an
1883 graduate of the Chicago Medical College (now
Northwestern University).49,52-54 But formal exclusionary
policies at the national level were not needed to maintain
near-total segregation, given the role of the state and
local societies. In actuality, the segregation of organized
medicine at the turn of the century was nearly complete—the AMA was almost entirely white; the NMA,
mostly black.
Segregated and Unequal Education
The AMA was conceived as an organization to
reform American medical education. At its founding
meeting in 1846, the AMA had established a Committee
on Medical Education (renamed the Council on Medical
Education, CME, in 1904). The CME reported annually
to the AMA national convention,55 and the policies and
initiatives it recommended would significantly impact
African Americans’ access to medical education.
Only a handful of African Americans graduated from
northern medical schools during the antebellum period.
Others, rebuffed by US schools, earned MDs abroad.
Among these early African American physicians were
James McCune Smith (1813-1865), perhaps the first
African American to earn an MD and practice in the
United States, who graduated from the University of
Glasgow in 1832,13 and Alexander Augusta, who was the
first African American to serve as a surgeon in the Union
Army (and one of the NMS members rejected from serving as an AMA delegate in 1870), who earned an MD
from Trinity Medical College in Toronto in 1856.56
Figure 2. Daniel Hale Williams (1856-1931)
African American Physician
Organizations
In the south, African American physicians responded
to their exclusion from AMA-affiliated medical societies
by founding their own local and state societies. The Medico-Chirurgical Society of the District of Columbia was
founded in 1884;42-45 the Lone Star State Medical, Dental,
and Pharmaceutical Association of Texas in 1886;46 the
Old North State Medical Society of North Carolina in
1887;47 and the North Jersey National Medical Association
in 1895.48 None of these societies could send delegations
to AMA meetings. In 1895, feeling the need for a national
organization to support black physicians, leading African
American physicians formed the NMA.3(pp392, 400-402),45,49,50
Notably, neither the NMA nor the AMA has ever had
any explicit, race-based membership criteria at the
national level. The NMA was “conceived in no spirit of
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
A renowned surgeon, Williams was the first African American
member of the American College of Surgeons, 1913. He
cofounded the NMA in 1895 and served as its first vice
president. AMA records indicate that Williams was an AMA
member as early as 1906.49
VOL. 101, NO. 6, JUNE 2009 507
African Americans and Organized Medicine
Following the war, southern medical schools continued to refuse black students. The few northern schools
that accepted African Americans generally did so in ones
and twos.6(pp302-321),45 In reaction, some of the missionary
groups that founded colleges in the Reconstruction
South (schools that today are called historically black
colleges and universities) also established medical
schools. For example, Meharry Medical College (Tennessee) was founded in 1876 and Leonard Medical
School (North Carolina) was founded in 1882.57(p1416)
Howard University was founded by a group of citizens
and an act of Congress, and its medical school opened in
1868 (Figure 3).58-60 Starting in the late 1880s, a few
black physicians established independent medical
schools as well. These schools were small and struggling
(Table 2). By 1890, 25 years after the Civil War ended,
there were only 909 black physicians in the entire United
States, although the census recorded nearly 7.5 million
African Americans.61
By 1907, the CME tracked state medical board licensure failure rates by medical school and had established
a grading system to assess school quality. African American schools (8 existed in 1907) fared badly. Their licensure failure rates were over 20% and the AMA rating
system routinely placed them in the bottom third of the
135 US medical schools examined.57 Moreover, since all
the African American schools lacked financial resources,
rising educational standards and increasing pressure for
reform created a crisis for these schools.
The crisis deepened after the CME asked the Carnegie Foundation for the Advancement of Teaching to
sponsor an on-site survey of all American and Canadian
medical schools in 1908. The foundation commissioned
Abraham Flexner (1866-1955), an educator from Kentucky, to head the study. Flexner was charged with
reviewing every medical school in North America. He
visited each school, usually accompanied by the secretary of the CME.55(pp10-11) Flexner’s 1910 report to the
foundation, Medical Education in the United States and
Canada,62 commonly known as the “Flexner report,” is
often credited with reforming American medical education.63 In truth, it was part of an ongoing and complicated evolution, but the report’s finding were especially
effective—and scathing.63-65 Approximately 90% of all
schools had inadequate admissions standards (for example, only 16 medical schools required a bachelor’s degree
from their applicants), most medical schools lacked
trained faculty, their curricular offerings were inadequate, and they failed to provide adequate laboratories
and clinical experience in hospitals.
The report’s recommendations for the reform of
American medical education were predicated on a basic
finding of
enormous over-production of uneducated and ill
trained medical practitioners…in absolute disregard of the public welfare.…Taking the United
States as a whole, physicians are four or five
times [more] numerous in proportion to the population [than needed].”62(x)
Assessing the need for medical schools in a given state
in terms of the number of physicians required to serve
that state’s population, Flexner recommended closing
weak schools so that resources could be focused on
stronger schools.
Flexner abandoned his population-based standard,
however, when assessing the need for African American
medical schools to serve the 9.8 million African Americans living in the United States in 1910.66 Given segregation, a population-based assessment would have supported a substantial increase in the number of African
Figure 3. Few Medical Schools Open to African American Students
First class of Leonard Medical School at Shaw University, Raleigh, North Carolina circa 1886 (left). The Howard University medical
faculty, Washington, DC, 1869-1870 (right). Left to right: Alexander T. Augusta, Silas L. Loomis (Dean), Gideon S. Palmer, Major General
Oliver O. Howard (President), Robert Reyburn, Joseph Taber Johnson (secretary), Charles B. Purvis, and Phineas H. Strong.40(p42) In:
Virtual Museum of African American Medical History in North Carolina. Old North State Medical Society Web site. http://www.
oldnorthstatemedicalsociety.org/virtualMuseum/Main%20-%20ONSMS%20Virtual%20Museum.html. Accessed January 28, 2008.
508 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
VOL. 101, NO. 6, JUNE 2009
African Americans and Organized Medicine
American physicians. To accomplish this, Flexner could
have recommended several strategies: integrating African Americans into white medical schools (as he recommended the coeducation of women physicians), creating
segregated branches at high-quality white schools, providing resources to improve poor-performing African
American schools, or increasing enrollment at existing
high-quality African American schools. Flexner recommended none of these. Instead, arguing that African
Americans needed “good schools rather than many
schools,” he recommended the closure of all but 2 of the
7 African American medical schools operating in 1910—
Howard and Meharry—without recommending any
mechanism to increase the total output of black physicians. Flexner, thereby, left black patients in the segregated south—where, at the time, more than 90% of the
black population resided67—with even fewer sources of
African American physicians.
Flexner seemed to appreciate that he was applying a
double standard in assessing the need for African American physicians. He addressed the issue by observing that,
while the “practice of the negro doctor will be limited to
his own race,” the “medical care of the negro race will
never be wholly left to negro physicians.”62(p180) Flexner,
thus, suggested that the medical care of African Americans would, ultimately, be entrusted to white physicians.
But by parity of reasoning—and as was true under segregation—it follows that white physicians in the Jim Crow
south would primarily serve their people, leaving black
populations medically underserved, caught in a racially
segregated system that was both separate and destined to
remain unequal under Flexner’s recommendations. Further cementing the unequal status of African American
medical education, Flexner recommended that “negro
doctors” be educated not as surgeons or other specialists
but primarily as “sanitarians,” to “humbly and devotedly”
teach hygienic principles to “their people.”62(p180)
The Flexner report was initiated at the request of the
AMA and was meant to buttress the work of the CME.55(pp10,5859),68-72
The AMA embraced Flexner’s recommendations
wholeheartedly and in annual evaluations of medical
schools in the Journal of the American Medical Association, the CME kept up the pressure for reform. By 1923, 51
of the 131 (40%) US medical colleges operating in 1910
had closed. Amongst these were 5 of the 7 (71%) African
American medical colleges; only Howard and Meharry
remained open (Table 2). Both struggled for survival.57,72
In the decade following the report, the General Education Board (GEB)—the Rockefeller family’s philanthropic foundation—and the Carnegie Foundation, both
advised by Flexner, donated large sums of money to establish new medical schools and to reform existing schools.
Flexner did not, however, immediately recommend adequate increases in funding for Howard and Meharry to
help them meet the new education standards.57 Meanwhile, the CME continued to give Howard and Meharry
low ratings each year, keeping them in constant jeopardy.
Toward the end of the decade Flexner became an important supporter of Meharry in particular and, after funding
white schools first, the Carnegie Foundation and GEB
eventually provided substantial funding to Meharry.57
Table 2. Black Medical Colleges, 1868-1923
Year
Year
Opened Discontinued
Name
City
Howard University Medical Dept
Lincoln University Medical Dept
Straight University Medical Dept
Washington, DC 1868
Oxford, PA
1870
New Orleans
1873
---1874
1874
Meharry Medical College
Leonard Medical School of
Shaw University
Louisville National Medical College
Flint Medical College of New Orleans
University
Hannibal Medical College
Knoxville College Medical Dept
Chattanooga National Medical College
State University Medical Dept
Nashville
Raleigh
1876
1882
---1918
None
Presbyterian (local)
American Missionary
Association
Methodist Episcopal
Baptist
Louisville
New Orleans
1888
1889
1912
1911
Independent
Methodist Episcopal
Memphis
Knoxville
Chattanooga
Louisville
1889
1895
1899
1899
Knoxville Medical College
University of West Tennessee College
of Medicine & Surgery
Medico-Chirurgical & Theological
College of Christ’s Inst.
Knoxville
Jackson
Memphis
Baltimore
1900
1900
1907
1900
1896
1900
1904
1903 merged
with LNMC
1910
1907
1923
1908?
Independent
Presbyterian
Independent
Colored Baptist
(Kentucky)
Independent
Independent
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Religious Affiliation
Independent
VOL. 101, NO. 6, JUNE 2009 509
African Americans and Organized Medicine
Discussion
In the United States, organized medicine emerged
from a society deeply divided over slavery, but largely
accepting of racial inequities. Throughout this period,
racism was pervasive, and pseudoscientific theories of
racial inferiority were common. Hospitals, training programs, and many medical and nonmedical organizations, in addition to the AMA, accepted or enforced
racial segregation.
Yet, one might have expected the AMA to lead the
way in integration, since its code of ethics and formal
membership policies specifically valorized only science,
education, and character and made no mention of race.
Indeed, when AMA actions effectively broke from this
ideal—in refusing to admit the NMS delegation in
1870—it felt the need to claim it was doing so for nonracial reasons, the decision was contentious, and it was
criticized for turning on its own code of ethics.
Instead of standing for its stated ideals, however, the
AMA adopted policies that countenanced medical segregation and racism. As AMA President Baldwin observed
in 1869, the AMA had, indeed, taught postwar “charity
and forgiveness,” but reconciliation was on white southern terms—on the terms offered by the MSDC, which
was practicing discrimination that courts had ruled
unconstitutional—and came at the expense of the civil
rights of blacks. Moreover, early in Reconstruction, more
than 20 years before the Plessy v Ferguson US Supreme
Court case endorsed legalized segregation,73 the AMA
modeled a states’ rights solution to maintaining national
professional unity by allowing outright professional segregation and racial exclusion at the state and local level.
Then, in pursuing a quality improvement agenda that
promoted the closure of most African American medical
schools, the AMA effectively helped to deprive many
African American patients of access to well-trained African American physicians. For the medical profession, as
for the nation as a whole, this postwar path to reconciliation ultimately created a false unity, a partial unity that
included only white physicians. Professional unity based
on allowing racial exclusion would prove to be unteneble, yet profoundly damaging, in the decades to come.
Acknowledgments
The authors are indebted to the following individuals
for their support of this project: John C. Nelson, MD,
MPH, past president, AMA; Sandra L. Gadson, MD,
past president, NMA; Ronald M. Davis, MD, past president, AMA; Phyllis R. Kopriva, director, Special Groups,
AMA; and Arthur B. Elster, MD, former director, Medicine and Public Health, AMA.
We also extend our thanks to Laura L. Carroll, MA,
MLIS, archivist, Emory University, and former archivist, AMA; and Andrea Bainbridge, archivist, AMA, for
their assistance in locating primary source data and other
records at the AMA.
510 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
For their helpful comments on previous drafts of this
paper, the Writing Group thanks John S. Haller Jr, PhD,
vice president for academic affairs, Southern Illinois
University, Carbondale; Douglas M. Haynes, PhD, associate professor of history, University of California,
Irvine; Darlene Clark Hine, PhD, board of trustees professor of African American studies, and professor of history, Northwestern University; Kenneth M. Ludmerer,
MD, professor of medicine, Washington University;
Katya Gibel Mevorach, PhD, associate professor of
anthropology and American studies, Grinnell College;
Susan M. Reverby, PhD, MA, Marion Butler McLean
Professor of Women’s Studies, Wellesley College; David
Barton Smith, PhD, research professor, Center for Health
Equality and Department of Health Management and
Policy, Drexel University School of Public Health, and
professor emeritus, Department of Risk, Insurance, and
Health Care Management, Fox School of Business, Temple University; and Karen Kruse Thomas, PhD, associate director, Reichelt Oral History Program, Florida
State University, and adjunct assistant professor of History, University of Florida.
The Writing Group on the History of African Americans and the Medical Profession includes Robert Baker,
PhD, The Union Graduate College-Mount Sinai School
of Medicine Bioethics Program, and Department of Philosophy, Union College; Janice Blanchard, MD, George
Washington University School of Medicine, Department
of Emergency Medicine; L. Ebony Boulware, MD,
MPH, Johns Hopkins Medical Institutions, Welch Center for Prevention, Epidemiology, and Clinical Research;
Clarence Braddock, MD, MPH, Stanford Center for
Biomedical Ethics; Giselle Corbie-Smith, MD, MSc,
Department of Social Medicine, University of North
Carolina at Chapel Hill; LaVera Crawley, MD MPH,
Stanford University Center for Biomedical Ethics; Eddie
Hoover, MD, editor, Journal of the National Medical
Association; Elizabeth Jacobs, MD, MPP, Cook County
Hospital & Rush Medical College; Thomas A. LaVeist,
PhD, Johns Hopkins Bloomberg School of Public Health,
Department of Health Policy and Management; Randall
Maxey, MD, PhD, past president, NMA; Charles Mills,
PhD, University of Illinois at Chicago; Kathryn L. Moseley, MD, University of Michigan Medical School; Todd
L. Savitt, PhD, Department of Medical Humanities,
Brody School of Medicine, East Carolina University;
Harriet A. Washington, visiting scholar, DePaul University College of Law; David R. Williams, PhD, Institute
for Social Research, University of Michigan.
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